Provider Demographics
NPI:1093913519
Name:FREDERICK, CARLA ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:ANNE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HIGH ST
Mailing Address - Street 2:B8
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1126
Mailing Address - Country:US
Mailing Address - Phone:716-859-2271
Mailing Address - Fax:
Practice Address - Street 1:100 HIGH ST
Practice Address - Street 2:B8
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1126
Practice Address - Country:US
Practice Address - Phone:716-859-2271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256853207RP1001X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03306076Medicaid